scholarly journals Reproductive Diseases and Disorders of Female Camels: An Assessment and Pathological and Bacteriological Study in Eastern Ethiopia

2021 ◽  
Vol 2021 ◽  
pp. 1-14
Author(s):  
Dinaol Belina ◽  
Amare Eshetu ◽  
Sisay Alemu ◽  
Bekyad Shasho ◽  
Tajudin Mohammed ◽  
...  
Keyword(s):  
Reproductive Organs ◽  
Cross Sectional Study ◽  
Meat Production ◽  
Cross Sectional ◽  
Eastern Ethiopia ◽  
Bacteriological Study ◽  
E Coli ◽  
Pathological Lesions ◽  
Arid And Semiarid Areas ◽  
Staphylococcus Spp

Camels are the most efficient domesticated animals in arid and semiarid areas of the world. In Ethiopia, they are the main livestock kept to sustain the livelihoods of pastoralists, as camels are used for milk and meat production and also for transportation. However, she-camel reproductive diseases are one of the major constraints for camel-producing communities. A cross-sectional study was conducted from November 2018 to December 2019 to identify and characterize pathological lesions and isolate possible bacteria associated with reproductive diseases and disorders in she-camels slaughtered at Dire Dawa and Babille municipal abattoirs. A total of 155 study animals were examined by recruiting all she-camels slaughtered during every abattoir visit. Overall, 562 reproductive organs, the ovaries, oviducts, uterus, and cervix, were examined through observation, palpation, and incision, and the animal- and organ-level pathological lesion prevalence were found to be 29% and 64.6%, respectively. Degenerative changes, inflammatory lesions (endometritis and salpingitis), growth disturbances (e.g., ovarian hypoplasia), and noninflammatory lesions (e.g., noninflammatory edema) were the identified pathological lesions. Occurrences of pathological changes among reproductive organs had differences where significantly the highest proportion ( p  = 0.00) was observed in the uteri. Of the 119 microbiological samples processed, 77.3% were positive for single or mixed bacterial genera, from which 7 different bacterial isolates and 14 other unidentified Gram-negative bacteria were detected. E. coli, Salmonella, and Staphylococcus spp. were the most frequently isolated organisms with 28.2%, 26.9%, and 12.8% frequencies, respectively. The result of the questionnaire survey showed 74% of the respondents had culled the she-camel at productive age because of poor reproductive performance associated with refused mating, abortion, and repeat breeding (poor conception). On the other hand, a majority of camel herders had poor to no information and access to modern veterinary services; nevertheless, they had good indigenous knowledge on how to manage reproductive abnormalities. Considering the importance of camels in our study area, further research on camel reproductive diseases and abnormalities with wider sample and epidemiology need to be conducted using molecular and hormonal assay techniques.

scholarly journals Bacteriological study of nidus of gallstones

2019 ◽  
Vol 6 (9) ◽  
pp. 3271
Author(s):  
Christo Cyriac Thomas ◽  
Sreejith V. ◽  
Rosna Mary Anto ◽  
Fleming Nagarajan ◽  
Debaleena Goswami ◽  
...  
Keyword(s):  
Microbial Growth ◽  
Gallstone Disease ◽  
Gall Stone ◽  
Cross Sectional Study ◽  
Medical Sciences ◽  
Cross Sectional ◽  
Bacteriological Study ◽  
Gold Standard Method ◽  
E Coli ◽  
Infective Potential

Background: Gallstone disease is common worldwide and majority of patients undergo surgical management. Since the advent of laparoscopic cholecystectomy surgeons has become less interested in its aetiology. Infection is a major factor in the formation of gallstones. There are many infective complications reported of gallstones spilled during cholecystectomy. Presence of bacteria or its DNA by microscopy does not prove the infective potential of such stones. Thus culture of the nidus of the gallstone is the gold standard method to identify any potentially infective bacteria within and to predict the infective potential of gallstones.Methods: Cross sectional study done in seventy patients admitted for elective cholecystectomy for a period of 24 months from August 2016 to July 2018 in Department of Surgery, Regional Institute of Medical Sciences, Imphal, India.Results: Of the 70 stones cultured for bacteria, 52 (74.3%) were sterile and 18 (25.7%) were positive for bacteria, among which 16 stones showed mono-microbial growth while 2 showed poly-microbial growth. Most commonly isolated organism was E. coli and Klebsiella followed by Pseudomonas, Enterococcus and Staph aureus.Conclusions: Moynihan‘s aphorism “gall stone is a tomb erected in the memory of the organism within it”, suggest bacteria inside gallstone to be dead but this study proves that bacteria can be viable inside gallstone and its complete retrieval should be done in case of spillage which may help in avoiding complications. 

Pengetahuan Mahasiswi Universitas Al Azhar Indonesia Terhadap Premenstrual Syndrome

2015 ◽  
Vol 2 (3) ◽  
pp. 193
Author(s):  
Riris Lindiawati Puspitasari ◽  
Dewi Elfidasari ◽  
Kun Mardiwati Rahayu
Keyword(s):  
Premenstrual Syndrome ◽  
Population Sample ◽  
Reproductive Organs ◽  
Cross Sectional Study ◽  
Hormonal Control ◽  
P Value ◽  
Cross Sectional ◽  
Knowledge Age ◽  
Physical Changes ◽  
Age Of Menarche

<p><em>Abstrak –<strong> </strong></em><strong>Tahap perkembangan r</strong><strong>emaja ditandai </strong><strong>dengan</strong><strong> perubahan fisik umum </strong><strong>yang di</strong><strong>serta</strong><strong>i</strong><strong> perkembangan kognitif</strong><strong> maupun</strong><strong> sosial.<em> </em>Menstruasi merupakan </strong><strong>proses alamiah organ reproduksi wanita dengan </strong><strong>peng</strong><strong>e</strong><strong>ndalian hormon</strong><strong>. S</strong><strong>alah satu gangguan menstruasi adalah <em>Premenstrual Syndrome</em> </strong><strong>atau</strong><strong> sindrom sebelum haid</strong><strong> atau dikenal juga sebagai </strong><strong>ketegangan sebelum haid</strong><strong>.</strong><strong> </strong><strong>Siklus menstruasi yang tidak teratur, penurunan </strong><strong>level</strong><strong> progesteron dan peningkatan </strong><strong>level</strong><strong> estrogen, stres, usia <em>menarche</em> yang terlalu cepat, dan status gizi</strong><strong> merupakan beberapa faktor penyebab PMS. Penelitian ini bertujuan u</strong><strong>ntuk mengetahui pengetahuan mahasiswi Universitas Al Azhar Indonesia terhadap PMS<em>. </em></strong><strong>Metodologi yang digunakan yaitu studi <em>Cross Sectiona</em></strong><strong><em>l.</em></strong><strong> Populasi sampel penelitian adalah mahasiswi Universitas Al Azhar Indonesia. Variabel independen yang dipilih yaitu pengetahuan, usia <em>menarche</em>, siklus haid, olahraga, nutrisi, produktivitas, dan indeks massa tubuh (IMT). Berdasarkan uji </strong><strong>bivariat dan multivariat regresi logistik tidak ditemukan hubungan yang signifikan antara pengetahuan dengan premenstrual syndrome pada mahasiswi UAI yaitu pengetahuan dengan p value 0,169; OR 0,473; 95% CI 0,163-1,374</strong><strong>. Responden yang memiliki pengetahuan 0,473 kali lebih baik dalam penatalaksanaan <em>premenstrual syndrome</em> daripada responden yang memiliki pengetahuan kurang.</strong><strong></strong></p><p><strong> </strong></p><p><em>Abstract </em><strong>– Adolescent developmental</strong><strong> stage characterized by common physical changes that accompanied the cognitive and social development. Menstruation was known as a natural process of hormonal control in the female reproductive organs. One of menstrual disorders was premenstrual syndrome or syndrome before menstruation or also known as tension before menstruation. Irregular menstrual cycles, decreased levels of progesterone, increased level of estrogen, stress, menarche age, and nutritional status were informed as factors that cause premenstrual syndrome. This study aimed to determine student’s knowledge to premenstrual syndrome. The methodology used was a cross sectional study. The population sample was a student of University Al Azhar Indonesia. The independent variables were selected, namely knowledge, age of menarche, menstrual cycle, exercise, nutrition, productivity, and body mass index (BMI). Based on the test bivariate and multivariate logistic regression found no significant relationship between knowledge with premenstrual syndrome in UAI student that knowledge with p value 0.169; OR 0.473; 95% CI 0.163 to 1.374. Respondents who had knowledge 0.473 times better than others in treatment of premenstrual syndrome.</strong><strong></strong></p><p><strong><em> </em></strong></p><p><strong><em>Keywords</em></strong><em>: Premenstrual Syndrome</em><em>, </em><em>knowlwdge, menstruation, menarche.</em><em></em></p>

The effect of type of water supply on water quality in a developing community in South Africa

1997 ◽  
Vol 35 (11-12) ◽  
pp. 35-40 ◽  
Author(s):  
B. Genthe ◽  
N. Strauss ◽  
J. Seager ◽  
C. Vundule ◽  
F. Maforah ◽  
...  
Keyword(s):  
Water Quality ◽  
Water Supply ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
E Coli ◽  
Guideline Values ◽  
Developing Communities ◽  
Quality Guideline ◽  
And Control ◽  
The Relationship

Efforts to provide water to developing communities in South Africa have resulted in various types of water supplies being used. This study examined the relationship between the type of water supply and the quality of water used. Source (communal taps, private outdoor and indoor taps) and point-of-use water samples were examined for heterotrophic plate counts (HPC), total and faecal coliforms, E. coli, and coliphages. Ten percent of samples were also analysed for enteric viruses, Giardia and Cryptosporidium. Approximately 320 households were included in a case-control study. In addition, a cross-sectional study was conducted. Both studies examined the relationship between different types of water facilities and diarrhoea among pre-school children. The source water was of good microbial quality, but water quality was found to have deteriorated significantly after handling and storage in both case and control households, exceeding drinking water quality guideline values by 1-6 orders of magnitude. Coliphage counts were low for all water samples tested. Enteric viruses and Cryptosporidium oocysts were not detected. Giardia cysts were detected on one occasion in case and control in-house samples. Comparisons of whether in-house water, after handling and storage, complied with water quality guideline values demonstrated households using communal taps to have significantly poorer quality than households using private outdoor or indoor taps for HPC and E. coli (χ2 = 14.9, P = 0.001; χ2 = 6.6, P = 0.04 respectively). A similar trend (although not statistically significant) was observed for the other microbial indicators. The cross-sectional study demonstrated an apparent decrease in health risk associated with private outdoor taps in comparison to communal taps. This study suggests that a private outdoor tap is the minimum level of water supply in order to ensure the supply of safe water to developing communities.

scholarly journals Prevalence of MDR organism (MDRO) carriage in children and their household members in Siem Reap Province, Cambodia

2020 ◽  
Vol 2 (4) ◽  
Author(s):  
Shweta R Singh ◽  
Bunsoth Mao ◽  
Konstantin Evdokimov ◽  
Pisey Tan ◽  
Phana Leab ◽  
...  
Keyword(s):  
Final Analysis ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Middle Income ◽  
E Coli ◽  
Middle Income Countries ◽  
Siem Reap ◽  
High Prevalence ◽  
Significant Public Health ◽  
History Of

Abstract Background The rising incidence of infections caused by MDR organisms (MDROs) poses a significant public health threat. However, little has been reported regarding community MDRO carriage in low- and middle-income countries. Methods We conducted a cross-sectional study in Siem Reap, Cambodia comparing hospital-associated households, in which an index child (age: 2–14 years) had been hospitalized for at least 48 h in the preceding 2–4 weeks, with matched community households on the same street, in which no other child had a recent history of hospitalization. Participants were interviewed using a survey questionnaire and tested for carriage of MRSA, ESBL-producing Enterobacterales (ESBL-E) and carbapenemase-producing Enterobacterales (CPE) by culture followed by antibiotic susceptibility testing. We used logistic regression analysis to analyse associations between collected variables and MDRO carriage. Results Forty-two pairs of households including 376 participants with 376 nasal swabs and 290 stool specimens were included in final analysis. MRSA was isolated from 26 specimens (6.9%). ESBL-producing Escherichia coli was detected in 269 specimens (92.8%) whereas ESBL-producing Klebsiella pneumoniae was isolated from 128 specimens (44.1%), of which 123 (42.4%) were co-colonized with ESBL-producing E. coli. Six (2.1%) specimens tested positive for CPE (4 E. coli and 2 K. pneumoniae). The prevalence ratios for MRSA, ESBL-producing E. coli and ESBL-producing K. pneumoniae carriage did not differ significantly in hospital-associated households and hospitalized children compared with their counterparts. Conclusions The high prevalence of ESBL-E across both household types suggests that MDRO reservoirs are common in the community. Ongoing genomic analyses will help to understand the epidemiology and course of MDRO spread.

scholarly journals Timely Initiation of Breast Feeding and Associated Factors among Caesarian Section Delivered Mothers in Health Facilities of Dessie City Administration, North Eastern Ethiopia

2020 ◽  
Vol 13 (1) ◽  
pp. 1-8
Author(s):  
Roza Shiferaw ◽  
Sisay Eshete Tadesse ◽  
Tefera Chane Mekonnen ◽  
Aregash Abebayehu Zerga
Keyword(s):  
Cesarean Section ◽  
Breast Feeding ◽  
Associated Factors ◽  
Statistical Significance ◽  
Data Entry ◽  
Binary Logistic Regression ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Timely Initiation ◽  
Eastern Ethiopia

Objective: To assess the magnitude and associated factors of timely initiation of breastfeeding among cesarean section delivered mothers. Methods: A health facility-based cross-sectional study was employed among 421 systematically selected mothers from February to June, 2017. Data were collected by a structured questionnaire. Data entry and analysis was done using Epi Data and SPSS version 24. Binary logistic regression was computed to identify factors. Adjusted odds ratio with a 95% confidence interval was used to declare statistical significance. Result: The magnitude of timely initiation of breast feeding (among mothers who gave birth by cesarean section was 57%. Counseling during antenatal care (AOR = 3.32; 95% CI: 1.80, 6.13), facility where cesarean section (CS) was performed (AOR = 2.55; 95% CI: 1.57, 4.14), and post-CS counseling (AOR = 6.93; 95% CI: 3.99, 12.02) were factors that contributed for the practice of timely initiation among cesarean section delivered mothers. Conclusions: The magnitude of TIBF was good. Counseling during ANC, the facility where CS was performed and post-natal advice were factors associated with TIBF. Implementation of baby-friendly hospital initiatives should be strengthened in order to promote timely initiation of breast feeding.

scholarly journals Emergency Contraceptives: Knowledge and Practice towards Its Use among Ethiopian Female College Graduating Students

2019 ◽  
Vol 2019 ◽  
pp. 1-8 ◽  
Author(s):  
Kirubel Minsamo Mishore ◽  
Abebaw Demissie Woldemariam ◽  
Solomon Assefa Huluka
Keyword(s):  
Educational Status ◽  
Cross Sectional Study ◽  
Female Students ◽  
Good Knowledge ◽  
Cross Sectional ◽  
Eastern Ethiopia ◽  
Female College ◽  
Knowledge And Practice ◽  
Graduating Students ◽  
Emergency Contraceptives

Introduction. Ethiopia has a high incidence of unwanted pregnancies and incomplete and unsafe abortions, particularly among adolescents. This can be avoided by using different contraceptive methods including emergency contraceptives (EC). This study aimed to assess the knowledge and practice of EC among female college graduating students in Harar, Eastern Ethiopia. Methods. Institution based cross-sectional study was conducted on 214 female students selected from two randomly selected colleges. Data was collected using a self-administered questionnaire and analyzed using SPSS for Windows version 20.1. Level of significance was taken at P <0.05. Results. The mean (±SD) age of the participants was 21.06 (±2.14) years. Of the 200 (93.5%) study participants who had ever heard of ECs, 140 (70.0%) had good knowledge. Among the 214 graduating female students, 66 (33.0%) had ever used EC. Being above the age of 20 years old, father’s and mother’s literacy were found to be determinants of knowledge of EC. Moreover, knowledge was the only determinant factor of practice of EC. Conclusion. Most of the respondents had relatively good knowledge of EC. The study revealed that female students of older age and higher educational status of parents had higher knowledge and practice of EC.

scholarly journals Hepatitis B virus infection and its associated factors among medical waste collectors at public health facilities in eastern Ethiopia: a facility-based cross-sectional study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Degu Abate Mengiste ◽  
Abebe Tolera Dirbsa ◽  
Behailu Hawulte Ayele ◽  
Tewodros Tesfa Hailegiyorgis
Keyword(s):  
Hepatitis B Virus ◽  
Hepatitis B ◽  
Cross Sectional Study ◽  
Medical Waste ◽  
Health Facilities ◽  
Sectional Study ◽  
Cross Sectional ◽  
Eastern Ethiopia ◽  
B Virus ◽  
History Of

Abstract Background The risk of hepatitis B virus infection among medical waste handlers who undergo collection, transportation, and disposal of medical wastes in the health institutions is higher due to frequent exposure to contaminated blood and other body fluids. There is limited evidence on the seroprevalence of hepatitis B among medical waste handlers in eastern Ethiopia. The study was aimed at studying the seroprevalence of Hepatitis B Virus and associated risk factors among medical waste collectors at health facilities of eastern Ethiopia. Methods A facility-based cross-sectional study was conducted among randomly selected medical waste collectors from public health facilities in eastern Ethiopia from March to June 2018. A pre-tested and well-structured questionnaire was used to collect data on socio-demographic characteristics and hepatitis B infection risk factors. A2.5ml venous blood was also collected, centrifuged and the serum was analyzed for hepatitis B surface antigen using the instant hepatitis B surface antigen kit. Descriptive summary measures were done. Chi-square and Fisher exact tests were used to assess the risk of association. Multivariate logistic regression was conducted with 95% CI and all value at P-value < 0.05 was declared statistically significant. Results From a total of 260 (97.38%) medical waste collectors participated, HBV was detected in 53 (20.4%) of the participants [95%CI; 15.8, 25.6]. No significant differences were observed in the detection rates of HBV with respect to socio-demographic characteristics. In both bivariate and multivariable logistic regression analysis, being unvaccinated (AOR = 6.35; 95%CI = [2.53–15.96], P = 0.001), history of blood transfusion (receiving) (AOR; 3.54; 95%CI; [1.02–12.24], P = 0.046), history of tattooing (AOR = 2.86; 95%CI = [1.12–7.27], p = 0.03), and history of multiple sexual partner (AOR = 10.28; 95%CI = [4.16–25.38], P = 0.001) remained statistically significantly associated with HBsAg positivity. Conclusion This cross-sectional study identified that HBV infection is high among medical waste collectors in eastern Ethiopia. Immunization and on job health promotion and disease prevention measures should be considered in order to control the risk of HBV infection among medical waste collectors in eastern Ethiopia.

scholarly journals An Increased Adverse Fetal Outcome Has Been Observed among Teen Pregnant Women in Rural Eastern Ethiopia: A Comparative Cross-Sectional Study

2021 ◽  
Vol 8 ◽  
pp. 2333794X2199915
Author(s):  
Haymanot Mezmur ◽  
Nega Assefa ◽  
Tadesse Alemayehu
Keyword(s):  
Pregnant Women ◽  
Fetal Outcome ◽  
Cross Sectional Study ◽  
World Health ◽  
Adult Women ◽  
Sectional Study ◽  
Fetal Outcomes ◽  
Cross Sectional ◽  
Eastern Ethiopia ◽  
Adverse Fetal Outcome

Background: According to the World Health Organization, teenage pregnancies are high-risk due to increased risks of fetal and infant morbidity and mortality. This study compares adverse fetal outcomes between teen and adult pregnant women from rural Eastern Ethiopia. Methods: Institutional-based cross-sectional study was conducted among women visiting maternity units from surrounding rural areas. A total of 481 teenagers (13-19 years old) and 481 adults (20-34 years old) women with a singleton pregnancy were included in the study. Two hospitals and 3 health centers were selected in Eastern Hararghe Zone, Eastern Ethiopia. Comparative analysis was carried out using the log-binomial regression model to identify factors associated with adverse fetal outcomes in both categories. The results are reported in adjusted prevalence ratios with 95% confidence intervals. Results: High proportion of adverse fetal outcome was observed among teenage women than adult (34.9% vs 21%). Statistically significant difference ( P < .05) in the proportion of low birth weight (21.1% vs 9.3%), preterm birth (18.7% vs 10.6%), APGAR score at 5th minute (9.3% vs 4%) were found in teenagers compared to adult women. Antenatal care attendance (APR = 0.44; 95% CI: 0.23, 0.86); eclampsia (APR = 1.96; 95% CI: 1.26, 3.06); pre-eclampsia (APR = 1.73; 95% CI: 1.12, 2.67); and wealth index (rich) (APR = 0.55; 95% CI: 0.32, 0.94) were significantly associated with adverse fetal outcomes among the teenage women. Whereas intimate partner violence (APR = 2.22; 95% CI: 1.26, 3.90); preeclampsia (APR = 3.05; 95% CI: 1.61, 5.69); antepartum hemorrhage (APR = 2.77; 95% CI: 1.73, 4.46); and hyperemesis gravderm (APR = 1.75; 95% CI: 1.09, 2.79) were significantly associated with adverse fatal outcomes among the adult women. Conclusion: teenage pregnancy is associated with a high rate of adverse fetal outcomes. Early identification and treatment of problems during antenatal follow-up should be the mainstay to avert the massive adverse fetal effects.

A Comparative Cross-Sectional Study to compare the Isolated Organism and their Antibiotic Sensitivity Pattern Between Community-Acquired Pneumonia (CAP) and Ventilator-Associated Pneumonia (VAP) in Intensive Care Unit (ICU).

2021 ◽  
Vol 11 (Number 2) ◽  
pp. 26-34
Author(s):  
Nahian Ahmed Chowdhury ◽  
Dipak Kumar Mitra ◽  
Afrin Ahmed Clara ◽  
Md. Suhail Alam ◽  
MD. Zahed Hossain
Keyword(s):  
Medical Information ◽  
Antibiotic Sensitivity ◽  
Cross Sectional Study ◽  
Community Acquired Pneumonia ◽  
Ventilator Associated Pneumonia ◽  
Sectional Study ◽  
Cross Sectional ◽  
Mechanically Ventilated ◽  
Sensitivity Pattern ◽  
Staphylococcus Spp

Background: The moment most common cause of in-hospital infection is pneumonia. Pneumonia is prevalent within the ICU (Intensive Care Unit) setting and can be deadly. The Incidence of pneumonia is approximately 17% in the therapeutic ICU2 but can be 6 to 20 times increased in mechanically ventilated patients. The duration of hospital stay and expenditure are both expanded in patients who develop ventilator-associated pneumonia. This study aims to identify the causative microorganism responsible for CAP (Community-Acquired Pneumonia) and VAP (Ventilator-Associated Pneumonia) and their antibiotic sensitivity pattern. Methods: This was a comparative cross-sectional study that was carried out at two ICU in Sylhet city. The data was collected from the patient's medical information, the patient's file, and the hospital information system. Culture and sensitivity (C/S) were collected from the electronic medical information system (MIS). All data from January 2019 to December 2020, including patient's information, course of the disease (in terms of death or recovery-if available), clinical features, and investigation reports, was transferred to an electronic data collection sheet (Microsoft Excel). After completion of all data collection, analysis was conducted through a spreadsheet. Comparison between two disease groups was made by independent t-test. Within the group, the analysis was done by the Chi-Square test. Results: In this thesis study, it was found that the most common organism responsible for CAP was Streptococcus spp. (34.70%) and is sensitive to Meropenem (92.21%), Imipenem (88.16%), Amikacin (70.67%), Piperacillin (70.91%), Moxifloxacin (70.96%), Levofloxacin (67.95%), Amoxiclav (67.92%), and Ceftriaxone(63.95%). The most common causative organism responsible for VAP was Staphylococcus spp. (36.51%) and it was sensitive to Imipenem (100%), Moxifloxacin (100%), Meropenem (94.73%), Amikacin (85.71%), Ceftriaxone (60%), Amoxiclav (66.66%), Levofloxacin (57.14%), and Cefuroxime (50%). Conclusion: Pneumonia is still one of the most common reasons for hospitalization, particularly for those admitted to ICU. It has been observed in several studies that the majority of the cases are communityacquired pneumonia. Many mechanically ventilated patients often develop VAP, which is fatal if timely diagnosis and appropriate antibiotics administration are not made. Streptococcus spp. was the most common organism responsible for CAP, and Staphylococcus spp. mainly was responsible for VAP.

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